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Inquest Conclusions

Date of inquest Date inquest concluded Name of deceased Conclusion
20/09/2017 04/10/2017 MAZUREK, Marcin Miroslaw Marcin Mazurek moved to the segregation unit at his own request following allegations of threats and bullying. During that time there was an incident of deliberate self-harm. An ACCT document was opened. A lack of effective intervention, failure to explore alternative support options other than segregation, led to Mr Mazurek spending an inappropriate length of confinement in segregation (51 days). A lack of adherence to the ACCT requirements meant insufficient involvement and intervention of Mental Health professionals. There was inadequate reporting and recording by both discipline and medical teams, leading to an omission of multi-disciplinary working and communication. Ultimately, there was a lack of holistic overview of Mr Mazurek's concerns and a systemic failure to meet his needs. All of these factors probably contributed to Mr Mazurek's death.
04/10/2017 04/10/2017 BENNETT, Lee Misadventure
04/10/2017 04/10/2017 DOYLE, Sean Anthony Drug related
04/10/2017 04/10/2017 ROACH, Steven Suicide
04/10/2017 04/10/2017 STARKIE, Phillip Alcohol related
04/10/2017 04/10/2017 TOMLINSON, Alexander Mr Tomlinson died as a result of natural causes, on a background of cardiac changes brought about by drug experimentation.
05/10/2017 05/10/2017 SMITH, Victoria Suicide
05/10/2017 05/10/2017 WALMSLEY, Garry Drug related death
11/10/2017 11/10/2017 CLIFFORD, Patrick Mr Clifford fell backwards following a faint in the toilet on Ward B4 at the Royal Blackburn Hospital on the 19th March 2016. He suffered a fractured acetabulum as a result. This was treated conservatively. His condition deteriorated over time. He developed pneumonia due to immobility and heart failure and passed away on the 18th September 2016 at Springhill care home in Accrington.
11/10/2017 11/10/2017 CONNOR, Michael Drug related death
11/10/2017 12/10/2017 HYLAND, Anthony Natural causes
11/10/2017 11/10/2017 LYNAS, Melvyn Stuart Suicide
11/10/2017 11/10/2017 WOOD, Sean James Sean James Wood died on 5 May 2017 on Chancery Road, Chorley due to self inflicted suspension however there is insufficient evidence to find that he intended to end his own life.
12/10/2017 12/10/2017 CURWEN, Marion Mary Accidental death
12/10/2017 12/10/2017 DICKINSON, Glynn Barry Suicide
12/10/2017 12/10/2017 MONTGOMERY, Raymond Joseph Accidental death
12/10/2017 12/10/2017 WHELAN, Rose Nancy Jane Misadventure
17/10/2017 17/10/2017 RICHARDSON, Stuart Natural causes
17/10/2017 18/10/2017 SINGH, Avtar Natural causes
18/10/2017 18/10/2017 BOLTON, Gary Accidental death
18/10/2017 18/10/2017 GREEN, Shane Ian Natural cause
18/10/2017 18/10/2017 McCORDKINDALE, Tamara Skye Accidental death
18/10/2017 18/10/2017 SHERLOCK, Frederick Graham Industrial disease
24/10/2017 24/10/2017 CLARKSON, Carn Misadventure
24/10/2017 24/10/2017 HEARSEY, Gerald Industrial death
24/10/2017 24/10/2017 SHIRLEY, Kimberly Alcohol and drug related
25/10/2017 25/10/2017 DURKIN, Richard Alan Accidental death
25/10/2017 25/10/2017 FENN, Peter David Drug related death
25/10/2017 25/10/2017 MURTON, Julie Misadventure
25/10/2017 25/10/2017 SIMPSON, Lily Accidental Death
26/10/2017 26/10/2017 HODGSON, Joan On 10 June 2016 in an unwitnessed fall at her home 16 Holland Avenue, Walton le Dale, Joan Hodgson suffered a head injury the treatment for which at Royal Preston Hospital included the administration of anti-coagulant medication which was not appropriately managed resulting in her death on 15 June 2016.
27/10/2017 27/10/2017 STANCHEV, Plamen Tilev Suicide
31/10/2017 31/10/2017 CLAPHAM, Susan Mary Mrs Clapham deliberately overdosed on prescribed medication and alcohol which I find directly contributed to her death, however there is no evidence to support that she intended this action to bring about her death at this time.
31/10/2017 02/11/2017 DALE, David David Dale died as the result of a road traffic collision.
31/10/2017 31/10/2017 KNOWLES, Carole Anne Natural cause
31/10/2017 31/10/2017 RAILTON, Stuart Accidental Death
01/11/2017 01/11/2017 GARNETT, Jill Accidental Death
01/11/2017 01/11/2017 HARTLEY, Lee Andrew Suicide
06/11/2017 28/11/2017 TALBOT, Christopher Shaun There was a failure with regards to monitoring the situation at the cell and subsequent lack of intervention which probably contributed towards to death.
07/11/2017 07/11/2017 HARVEY, Margaret Mrs Harvey was diagnosed with mesothelioma, a condition brought about by the exposure to asbestos, however in this case the evidence as to the source of that exposure is lacking.
08/11/2017 08/11/2017 BINNS, Alan Natural cause
08/11/2017 08/11/2017 BRADLEY, Dawn Alcohol related
08/11/2017 08/11/2017 HUTCHINSON, John Suicide
08/11/2017 08/11/2017 Manawar, Shakeel Road traffic collision
09/11/2017 09/11/2017 DAINTY, Andrew Suicide
09/11/2017 09/11/2017 SUTHERLAND, Paul Suicide
13/11/2017 13/11/2017 BEAN, Richard Road traffic collision
13/11/2017 13/11/2017 HOWARTH, Christopher William Mr Howarth died as a direct result of mesothelioma, a condition brought about by asbestos exposure, however the source of that exposure is not evidenced in this matter.
13/11/2017 13/11/2017 Nevett, Margaret Anne Misadventure
13/11/2017 13/11/2017 ZHANG, Yusen Road traffic collision
14/11/2017 14/11/2017 COOPER, John Drug related death
14/11/2017 14/11/2017 SAVAGE, Frederick Suicide
15/11/2017 15/11/2017 HARDMAN, Peter Francis Albert Drug related
15/11/2017 15/11/2017 MITCHINSON, Eric Natural cause
15/11/2017 15/11/2017 TAYLOR, Vicky Misadventure
15/11/2017 15/11/2017 TORMEY, Brian John Bosco Natural causes
16/11/2017 24/11/2017 COATES, Stephen Lewis The jury believe the commencement time of the recordable observations was 11:30 pm on the 8th April. The time was arrived at by estimates for the cell key holders and the nurse and assistant to arrive at the cell after the cell bell had been rung, with an allowance given for introductions and initial health related questions. Yes, the nurse should have taken a full set of observations within an hour of the first set. This was evidenced by the expert witnesses. The jury has arrived at a unanimous decision, based on the evidence and timings given by expert witnesses that Stephen COATES would have arrived at Accident and Emergency within two hours of his first observations being taken. On the balance of probabilities Stephen COATES would have survived. The decision was arrived at by accepting expert witness evidence. The jury agree that there was a gross failure to provide basic medical care to Stephen COATES. The jury have come to the conclusion that by the nurse not taking a full set of observations and a subsequent second set with follow up actions when the opportunity arose Stephen COATES' basic medical care was not met. And from that Stephen COATES' subsequent death was contributed to by neglect.
16/11/2017 16/11/2017 MALKOWSKI, Wojciech Suicide
20/11/2017 20/11/2017 Branston, Robert Suicide
20/11/2017 20/11/2017 DOWLING, Frederick Joseph Natural Causes
20/11/2017 20/11/2017 MARSLAND, Donald Industrial disease
20/11/2017 20/11/2017 TATE, Arnold Accident
21/11/2017 21/11/2017 PALMER, John Industrial disease
22/11/2017 22/11/2017 BERNARD, Ann Bernette Accidental death
22/11/2017 22/11/2017 Clayton, Stanley Stanley Clayton died at 3 Thirlmere Avenue, Burnley on 12 June 2017 from a lung cancer having been exposed to asbestos during his working life.
22/11/2017 22/11/2017 RAWSON, William Industrial disease
23/11/2017 23/11/2017 SAYERS, Peter Henry Peter Henry Sayers was found deceased on the 31st January 2017 at Flat 23 Maudland House Preston from an unknown cause.
29/11/2017 29/11/2017 HEWITT, Rachael Sarah Drug related death
30/11/2017 30/11/2017 EDGERTON, Kenneth Natural Causes
30/11/2017 30/11/2017 McLOUGHLIN, Roman Accidental Death
05/12/2017 05/12/2017 BLACKBURN, Bryan Accidental death
05/12/2017 05/12/2017 HODSON, John Accidental death
05/12/2017 07/12/2017 TAYLOR, Beverley Louise Beverley Louise Taylor died on 13 March 2015 at Royal Lancaster Infirmary. Ms Taylor was profoundly handicapped after sustaining herpetic encephalitis. Ms Taylor was admitted with a severe bronchopneumonia caused by infection and aspiration and her death was contributed to by inadequate antibiotic therapy and minimally by fluid overload.
06/12/2017 06/12/2017 MASON, Kenny Francis Suicide
06/12/2017 06/12/2017 MOODY, Maurice Accidental death
This is the only information that can be provided at this time.